Acute Kidney Injury:The Wessex Experience
Mark UniackeConsultant in Renal and Transplantation
Wessex Kidney CentreChair
Wessex AKI Clinical ForumWessex Strategic Clinical Network
Outline
1. AKI is everyone’s business.
2. The Challenge.
3. The Wessex AKI Clinical Forum.
4. The impact.
5. The Future.
AKI is everyone’s business
Distribution of AKI episodes across acute specialties, stratified by AKI stage.
Selby N M et al. CJASN 2012;7:533-540
AKI is not just a hospital concern
Portsmouth data:
375 prospectively acquired AKI cases (2010/2011)
AKI was found on admission and hence community acquired in 68%- community AKI was more severe by staging- sepsis was an important trigger
In those without CKD at baseline community acquired AKI was associated with a higher hospital and 6 month mortality (OR 3.5, 95% C.I. 1.135 – 10.6, p=.03)
The challenge
Community Hospital
Community -acquired AKI
Predisposing factorse.g. CKD, ACE inhibitors, diuretics, BPH
Protective factorse.g. Vaccination, hydration, antibiotics
Precipitating factors Pre-renal: e.g. D+V, sepsis, trauma, GI blood lossRenal: glomerulonephritisPost-renal: obstruction
Elective hospital admission
Other condition requiring hospital admission - no AKI on admission
Hospital discharge
Predisposing factorse.g. CKD, cardiac surgery
Protective factorse.g. good fluid balance
Precipitating factors Pre-renal: e.g. hypovolaemia, sepsisRenal: e.g. nephrotoxic drugs, contrastPost-renal: e.g. obstruction
Hospital -acquired AKI
Community - acquired AKI in hospital
Emergency hospital admission
ConsequencesLonger length of stayRenal replacement therapyDeathCosts
ConsequencesNew or worse CKDChronic renal replacement therapyMedication changeRehab/Nursing HomeDeathCosts
Risk of recurrent AKI Total AKI in hospital
The Whole Pathway
Guidelines
NephrologyReferral
Care Bundles
Research
Education
eAlertsBiomarkers
Prevention
Sick Day Rules
Follow up after discharge
The Patient
“Physicians are people who pour medicine, of which they know very little, into people of whom they know less”
Voltaire 18th Century
‘What does it take to be good at something in which failure can be so easy, so effortless?’
Atul Gawande 2007
AKI is not about bad doctors and nurses
AKI is a patient safety issue but it is recognised that clinicians need the support of robust systems, education, risk assessment, improved diagnosis and reliable interventions
Acute Kidney Injury National Programme
2.8 million population
7 Acute Trusts
9 CCGs
3 Community Trusts
Two regional renal units
Wessex AKI Clinical Forum
AKI Network Forum
• Wessex SCN
Regional AKI Leads
• Local Renal Units• Wessex/Dorset
Local Trust Leads
• Renal• ITU• MAU
The Forum
• Nephrologists
• NHS England SCN manager
• Trust AKI leads – currently 6
• CCG representatives
• Public Health Consultant
• Laboratory Lead
• Nurse specialist
• University of Southampton – Wessex CLARCH and HHR
• AHSN representative
• Acute Medicine/Renal Trainees
Founding principles
harmonizing the AKI pathway based on evidence and national guidelines will embed best practice
improve advice/guidance and referral practices sharing of expertise, manpower and other resources
a network provides a stronger platform to lobby for resources
collaborative research/audit
a point of accountability
Wessex AKI Clinical Forum2
01
4/1
5 W
ork
str
eam
s
Acute hospital care
E-alert subgroup
AKI Care Pathway
AKI hospital education
course
Primary care
AKI education workshops
AKI Care Pathway for Primary Care
Stakeholder engagement
AKI Awareness
and Education
Launch Event 15/4/15
AKI Outreach
Impact
Education steps in WessexHospital
Structured AKI Educational Programme targeting foundation and core trainees – based on the ALS model using practical scenarios
-Local leads
Primary Care
CCG Target events
- AKI workshops run by local nephrologist and GP
LAEDILocal awareness and early diagnosis scheme
McMillan GPs
Now supporting one GP to provide peer to peer AKI education in the community
AKI OutreachBournemouth Hospital 2014-2015
One specialist nurse (5 half days per week)
QA Portsmouth
Appointed AKI specialist nurse August 2015
University Hospital Southampton
Appointed AKI specialist nurse August 2015
Results of interventionData provided by Martin Southgate Clinical audit RBH
Paul Broom Biochemistry PGHJulia Knott Diabetes Secretary RBH
BL Intervention2014 June-Aug Sept-Dec
New AKI flags N= 188 148 ( n = 96 seen by ST)RIP 23 (14%) 8 (5%)Readmission(in 28 days) 45 (27%) 14 (9%)
LOS (Mean /St Dev) 15 days (19) 9 days (9) (*p=0.002)
CreatinineBL X 163Admission X 275Discharge X 192
Nephrologist referrals Unknown 29 (30% of those seen)
Stage 2 & 3
The Future
Wessex AKI Clinical Forum20
15/1
6 W
ork
stre
ams
Acute hospital care Primary care Community
Stakeholder engagement
AKI CQUIN guidance for
commissioners
Nurse EducationExpand Outreach
Undergraduate AKI medical education
Implement new AKI core medical teaching module
Local Awareness & Early Detection Initiative (LAEDI)
Develop AKI topic for GP Trainees
LMC engagement & education
GP ‘Train the Trainers’ module
Out of hours GP engagement
Set up community trust subgroup
Set up community pharmacy subgroup
Set up commissioners’
AKI meeting
Develop AKI Network website
Patient and family education.
To Finish
AKI appears to be a proxy indicator of a vulnerable subpopulation with high comorbidity who are at risk of future hospital admissions, recurrent AKI episodes, progressive decline in renal function and death.